5.  The applicant was born in 1959 and lives in the town of Krasnoobsk, the Novosibirsk Region. She had a daughter, Oksana Vladimirovna Belenko, born in 1983 but now deceased.
6.  On 14 August 2003 Oksana Belenko complained of feeling ill. She was trembling, felt pain in her limbs, was having delusions and was behaving strangely. That evening her parents called an ambulance. The doctor of the ambulance team, having decided that she was suffering from hysterical neurosis, gave her some sedatives and painkillers. Her condition became worse, so the next morning she was taken to the town hospital, accompanied by her parents. In the town hospital she was examined by the chief psychiatrist, Rz., and a neuropathologist, Pn. The applicant’s daughter was behaving hysterically: she was laughing, shouting, trying to run around and threw a trolley over. As she was showing signs of a serious psychiatric disorder, later that day she was transferred to a psychiatric clinic.
7.  It appears from her medical records that on admission to the clinic, the daughter did not react when spoken to, refused to submit to examination, and was moving her hands and legs around chaotically. The doctors at the clinic examined her and concluded that she was suffering from schizophrenia. No signs of any other illness or injury were evident at that time. Oksana Belenko was already in such a state that the clinical director decided to ask the District Court for authorisation for her continued confinement in the clinic. Her parents (her father and the applicant) did not object to the confinement.
8.  According to the applicant, during the first few days in the psychiatric clinic her daughter was still able to recognise her relatives and had some understanding of the people and things around her. According to the official records, her condition was very serious and continued to deteriorate, and her understanding of the situation was seriously impaired.
9.  On 16 and 17 August 2003 she was examined by the clinic’s doctors on duty, Kr. and Vas. She was administered Sibazon and Haloperidol injections.
10.  On 18 August 2003 the applicant’s daughter was examined first by a psychiatrist on duty and then by a team of three doctors, including the acting chief doctor, Yar., and two other doctors, Lkh. and Olkh. She did not react to their questions, her eyes were motionless, she shouted out sporadically, and dropped herself onto the bed. The expert team considered that she needed further inpatient treatment.
11.  On the same day the applicant asked the clinical director to release her daughter for further treatment at home. However, it was refused, the chief psychiatrist instead asking the court to issue a confinement order in respect of her.
12.  On 20 August 2003 the Zheleznodorozhniy District Court of Novosibirsk examined the clinical director’s request for Oksana Belenko’s further confinement to the psychiatric clinic. Neither the applicant nor her daughter participated in those proceedings. According to the applicant, she was not informed about the date or place of the hearing. The District Court authorised the further confinement.
13.  The applicant continued to visit her daughter in the clinic almost every day. According to her, on one occasion her daughter was taken by the clinic staff to a meeting with her directly from the shower; her head was wet and, as a result, she caught a cold. The clinic staff also allegedly prevented her from visiting her daughter.
14.  Oksana Belenko received treatment in the psychiatric clinic until 31 August 2003. It appears that her medical condition was very serious. Several examinations conducted within that period showed that she was suffering from a very rare disease, known as febrile expressionless schizophrenia of a pernicious nature. The illness is potentially fatal and has various symptoms, such as high fever, catalepsy (being stuck in rigid postures for hours), delusions, muteness, and excessive motor activity (constant movement). She was spending hours in her bed in a “foetal position”, with her hands and legs bent and pressed against her body. Treatment with psychotropic drugs only had a limited effect on her. In addition, because of her immobility and cataleptic postures she started developing decubitus ulcers (bedsores). According to the Government, between 18 and 31 August 2003 she was examined by doctors three times.
15.  On 26 August 2003 the applicant wrote a letter to the psychiatric clinic asking for her daughter to be released, insisting that she would be better treated at home by a visiting doctor. However, given the daughter’s state of health and mind, the request was refused.
16.  According to the applicant, during that period her daughter was being tied to her bed by the clinic staff. She and some of her relatives and friends saw ligature marks on her daughter’s hands and legs when they visited her in the clinic. The clinic staff, namely doctor L. and nurse B., denied tying her up.
17.  On 31 August 2003 the applicant’s daughter had a high fever. She was examined by a doctor, who concluded that she had developed pneumonia, aggravated by a cardiac valve defect. The applicant informed the hospital that her daughter had congenital heart disease and that her skin had developed a bluish color, so the doctors of the psychiatric clinic called a cardiologist from the town hospital. After examining her, the cardiologist recommended her immediate transfer there, which was implemented the same day.
18.  On 1 September 2003 the applicant’s daughter became worse and was transferred to the town hospital’s emergency unit. Doctor Pn. who examined her there discovered ligature marks on her body. On the same day the head of the hospital’s psychiatric department, Ls., made an entry in the daughter’s medical record which read “evidence of tying up on the shins and arms” (later reproduced in the expert report of 17 May 2005, see paragraph 32 below).
19.  It appears that in so far as pneumonia was concerned, her treatment with antibacterial drugs had some positive effects. An X-ray examination was carried out on 15 September 2003 but did not reveal any characteristic signs of pneumonia in her lungs.
20.  On 9 October 2003 the applicant’s daughter was transferred to the psychiatric department of the town hospital. It appears that as a result of the catalepsy, she had developed large purulent ulcers in the groin area. Two weeks later she was admitted to the surgical ward of the town hospital in connection with the ulcers and necrotic abscess.
21.  At some point, the relatives lost confidence in the doctors’ ability to treat her properly. They thought that she was being neglected and even ill‑treated in the various hospitals, starting to suspect that she might also have been sexually abused there. The applicant made several written complaints to the regional authorities.
22.  On an unspecified date the applicant’s daughter had a new episode of pneumonia, which the doctors related to the sepsis (inflammation) she had developed as a result of the purulent ulcers. She also developed tetraparesis (muscular weakness of all four limbs).
23.  On 27 October 2003 a special panel was set up by the regional administration, which examined Oksana Belenko’s case. It concluded that the doctors’ actions had been adequate, that the worsening of her condition was due to external factors, and that the actions of the doctors did not present any danger to her life.
24.  On 30 October 2003 the applicant’s daughter was admitted to the regional hospital. Her physical and mental health continued to deteriorate. According to the Government, while in the hospital she had continued to receive adequate medical care, such as treatment with fourth generation antibiotics.
25.  On 4 November 2003 the applicant lodged a written criminal complaint regarding the allegedly inadequate treatment of her daughter. On 14 November 2003 the investigator refused to open an investigation in this connection.
26.  On 7 December 2003 Oksana Belenko died.
27.  On 8 December 2003 doctors examined her body. The doctors who carried out the post-mortem (вскрытие) concluded that she had died as a result of cerebral oedema, related to her psychiatric condition and aggravated by the pneumonia. The examination did not reveal any ligature marks. At the same time the doctors discovered that her left hip was dislocated, and that she had purulent necrotic wounds in the groin area and on her shins.
28.  A few days after Oksana Belenko’s death, the applicant lodged a criminal complaint to have the doctors who had treated her daughter prosecuted. The inquiry was reopened.
29.  On 31 December 2003 investigator O., following an additional inquiry, decided not to open a criminal investigation into her death.
30.  On 4 February 2004 the Deputy Regional Prosecutor overruled the above decision and decided to open a criminal investigation, to be treated as a medical negligence case. The case was entrusted to investigator O.
31.  On 20 May 2004 the Presidium of the Novosibirsk Regional Court, by way of supervisory review, quashed the Zheleznodorozhniy District Court’s decision of 20 August 2003 (see paragraph 12 above). The Presidium held that Oksana Belenko’s relatives had not been duly informed of the hearing, and furthermore, that the District Court had not verified whether her condition had warranted her confinement. Since she had died by that time, it was decided that the proceedings should be discontinued.
32.  On 17 May 2004 a group of doctors from the No. 6 Regional Psychiatric Hospital examined her case and concluded that it was impossible to discern a direct link between her mental condition and her death. In their report, they concluded that the death had actually been caused by a brain oedema and pulmonary valve insufficiency caused by pneumonia. The experts approved the diagnosis of the psychiatric clinic and hospitals and confirmed that the methods and medication used to treat her had been appropriate.
33.  On 22 June 2004 the applicant was given victim status in the case (see paragraph 30 above).
34.  On 11 October 2004 the Serbskiy Institute of Psychiatry conducted a second psychiatric expert examination of Oksana Belenko’s case. It concluded that the doctors had made the correct assessment of her condition, and had prescribed and administered her adequate treatment in a timely manner.
35.  On 12 January 2005 a new forensic examination of the case concluded that she had died primarily as a result of the brain oedema caused by her psychiatric disorder. The expert team had at its disposal samples of tissue taken from her body during the post‑mortem examination and her medical records. The experts confirmed that the earlier diagnosis had been correct and that the treatment she had received had been adequate, excluding any possibility that she had died as result of inappropriate treatment. The report, in summarising the doctors’ earlier observations, noted that the examination of 1 September 2003 had revealed ligature marks on her shins and later mentioned marks on her arms.
36.  Between 14 and 28 January 2005 a new forensic examination was carried out of the tissue taken from various parts of Oksana Belenko’s body. In addition, the investigator held a face-to-face confrontation between the applicant and doctors L., P., and Zh. Several of the psychiatric clinic staff were questioned, as were staff of the town and regional hospitals.
37.  On 4 February 2005 the criminal investigation was closed, the investigator concluding that the applicant’s daughter had died of natural causes.
38.  On 5 May 2005 the Deputy Prosecutor of the Novosibirsk Region ordered that the case be reopened and informed the investigator of the additional steps to be taken.
39.  On 19 May 2005 the applicant requested the investigator in charge of the case to conduct an additional expert examination to establish the cause of her daughter’s death. In particular, the applicant alleged that her daughter had developed pneumonia because of the poor sanitary and hygienic conditions in the psychiatric clinic and the town hospital. In her opinion, her daughter had contracted the infection through her ulcers. In addition, the experts had failed to establish why her daughter had had ligature marks on her body. In the applicant’s opinion, the purulent wounds discovered on her daughter’s lower legs were not the “decubitus ulcers” caused by her immobility but rather a result of her being tied up in the psychiatric clinic. In addition, the expert reports did not establish the cause of her dislocated hip. The applicant invited the investigator to commission a new expert examination and put relevant questions to the experts.
40.  On 12 June 2005 the investigator decided to close the case again. According to the report of that date, the ligature marks discovered on Oksana Belenko’s body during her examination on 1 September 2003 had been located around her shins.
41.  On 11 July 2005 the case was reopened but then closed again on 14 July 2005.
42.  On 25 January 2006 the case was reopened by the supervising prosecutor but then closed again on 26 February 2006.
43.  The applicant contested the closure of the case in court.
44.  On 20 March 2006 the supervising prosecutor ordered the case to be reopened and the investigator to carry out additional investigative measures, such as identifying and questioning other patients of the psychiatric clinic and establishing the cause of the ligature marks discovered on her body during the examination of 1 September 2003.
45.  On 19 January 2007 the Zheleznodorozhniy District Court noted that the case file contained conflicting expert opinions on the cause of Oksana Belenko’s death. Furthermore, the cause of the second episode of pneumonia and the purulent wounds on the lower legs had not been established. The court instructed the investigator to commission a new comprehensive forensic examination (комплексная судебно-медицинская экспертиза) to establish the cause of her death, and to carry out other investigative measures if necessary.
46.  On 9 February 2007 the investigator commissioned the new comprehensive forensic examination, ordered by the court, into the cause of the death of the applicant’s daughter. He entrusted it to the No. 6 Regional Psychiatric Hospital. However, in 12 February 2007 the hospital refused to carry out the examination on the grounds that it had already prepared a similar report on the matter at an earlier date.
47.  On 9 March 2007 the investigator closed the case again.
48.  The applicant challenged that decision in court. On 26 June 2007 the Zheleznodorozhniy District Court ordered the investigation to be continued. The court held, in particular, that the refusal of the No. 6 Regional Psychiatric Hospital to conduct a new expert examination did not prevent the investigator from seeking an expert opinion from another competent institution elsewhere.
49.  On 13 August 2007 the court’s decision was upheld by the Novosibirsk Regional Court on appeal.
50.  The criminal investigation was reopened but closed again on 5 September 2007.
51.  In 2008 the applicant challenged the discontinuation of the criminal proceedings in court again. On 18 September of that year the Zheleznodorozhniy District Court examined the applicant’s complaint against the investigator’s decision of 5 September 2007 and ordered the case to be reopened. However, it appears from the documents submitted by the Government that this decision was not enforced and the case not reopened until 15 April 2011, as confirmed in a letter by the Zheleznodorozhniy District Prosecutor dated 19 April 2011.
52.  On 15 April 2011 the District Prosecutor quashed the decision of 5 September 2007 and ordered the case to be reopened again.
53.  On 20 April 2011 the investigator ordered another forensic examination of Oksana Belenko’s body to be commissioned and entrusted this task to the Krasnoyarsk Region Forensic Centre. However, on 22 April 2011 it refused to conduct the examination on the grounds that the investigator had failed to produce her medical records and the “tissue archive” (гистологический архив).
54.  On 20 May 2011 the investigator decided to close the case again. The investigator reiterated the findings of the earlier expert examinations of the case and in particular the report of 12 January 2005 (see paragraph 35 above). Among other things, the investigator acknowledged that it proved impossible to find the medical records of the applicant’s daughter and the “tissue archive” and that, as a result, the experts were not in a position to conduct an additional forensic examination into the cause of her death. He further noted that:
“... during the preliminary investigation it was established that ... [Oksana Belenko] had suffered from psychiatric disease in the form of schizophrenia, the febrile catatonic form. The reason for [her] death was [this disease]. From the medical examination report dated 12 January 2005 it follows that [her] death resulted from cerebral oedema, which itself had resulted from [the above-mentioned disease] ...
It was noted on 1 September 2003 that on a few occasions [she] had been seen as carrying [marks on her arms], but from the statements of the questioned persons, it was impossible to establish with certainty any facts of the use of violence (tying up) in respect of [her] ...
At the present time in this criminal case all of the indications of the Prosecutor’s office of the Novosibirsk Region were executed. The results of the conducted preliminary investigation demonstrated that no crime set out in Article 109 § 2 of the Criminal Code had taken place because [Oksana Belenko’s] death resulted from the cerebral oedema resulting from the psychiatric disease, that is from the natural factor, [her] treatment having been conducted in accordance with modern methods of treatment. It follows that the death of [Oxana Belenko] did not result from anyone’s unlawful actions.”
55.  It does not appear that there have been any developments in the applicant’s case since the decision of 20 May 2011.